I declare that I
1. Am 18 years or older, or have legal custody of the herein named staff member applying to Camp Mishewah or staff member is of of legal age.
2. Declare that the herein named staff member is in good physical and emotional health and amenable to Camp Mishewah authority.
3. Am responsible for payment of fees and any other expenses incurred by herein named staff member.
4. Declare that the herein named staff member attending Camp Mishewah is covered by their provincial health plan or equivalent medical insurance.
6. Declare that I have submitted the staff member's up-to-date medical information and agree with the following Consent to Treatment statements:
• To the best of my knowledge, the staff member is in good health. If the staff member becomes exposed to any serious/infectious diseases within four weeks of attending camp, I will notify the Camp Directors.
• I understand that, if the staff member is under the age of 18, every effort will be made to contact parents before any major treatment is administered.
• In case of a surgical emergency where parent am not available for consultation, I as the parent/guardian hereby give permission to the physician selected by the Camp Director or designate to hospitalize, secure proper treatment for and to order injections, anesthesia, or surgery for the staff member.
• I give permission for the Camp Nurse or trained personnel to administer stock medications that are approved by a physician in case of minor injury, and/or illness during the staff member’s stay at Mishewah.
• I also give permission for the Camp Nurse or trained personnel to provide Standard First Aid to the staff member as appropriate.
• I give permission for the Camp Health Nurse or trained personnel to administer medications provided by me as per indicated on the submitted health form.
• I give permission for Epinephrine to be administered to the staff member in case of an anaphylactic (life-threatening) reaction.
• I agree that all the information given on the Staff Health & Medical Form is correct and complete.
• By signing, I agree to pay all health related expenses and treatments not covered by the Provincial Health Plan (ie. lice treatments, medications, dressing supplies, casts, etc.)
7. Give permission to Camp Mishewah to use photographs of the herein named staff member for promotional material.*
8. Give permission for the herein named staff member to be transported by bus or personal vehicle to offsite locations for hiking, canoeing, and excursions or to be taken to the hospital/clinic for medical treatment if necessary.
9. Give permission for the herein named staff member to participate at Camp Mishewah, its facilities, programs and activities. All physical programs and activities have risks and I understand there are physical risks and hazards inherent in any program or activity. I am allowing the staff member to participate and understand that I am exposing my child, or myself if of legal age, to inherent risks and hazards. I agree to accept all risks and hazards and be responsible for any injury or other loss which may occur during my child's (or my) participation. I understand that reasonable precautions shall be taken to ensure the health and safety of the herein named staff member.
* If you do not want photos of staff member used, please send an explanation to
[email protected]
Thank you.
